Roller Derby Risk Agreement, Acknowledgement, & Release of Liability I, _________________________, completely understand that roller derby is a dangerous full contact sport. Practice consists of, and is not limited to, falling, speed drills, blocking, stopping, whipping, jamming, and skating backwards. I have been notified by Brentwood Brawlin’ Betty’s that wrist guards, elbow pads, kneepads, mouth guard, and a helmet are required at all times while during practice, team sponsored skates and events, and bouts. Eyeglasses must have plastic shatterproof lenses. The undersigned must take full responsibility that the she is wearing the specified safety equipment at all times and that it is properly worn. Only quad speed skates are permitted. I understand that even with the required gear there is a possibility of being injured, by my action or by the action of others. I understand that the very nature of roller derby is very aggressive and much of the strategy of roller derby requires vigorous contact with other people, both on my team, as well as competing teams. There is a high likelihood that I can be injured while practicing individually, paired, or as a team. The risk of inquiries from the activities involved in this program is significant, including potential for permanent paralysis and death, and while particular rules, equipment and personal discipline may reduce the risk, the risk of serious injury remains. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releasees or others, and I assume full responsibility for my participation. Brentwood Brawlin’ Betty’s has advised me that medical and dental insurance is highly recommended. Additionally, Brentwood Brawlin’ Betty’s highly suggests USA Roller Sports (USARS) for injury insurance for practices and is required to participating during bouts. I will be financially responsible for all payments and deductibles as required by USARS. I, for myself and on behalf of my heirs, personal representatives and next of kin, hereby release and hold harmless any Brentwood Brawlin’ Betty’s league members, Paradise Skate, skating rinks, venues, coaches, their officials, agents, and competing teams (“Releasees”) with respect to any and all injury, disability, death, or loss, or damage to person or property, whether arising from the negligence of the releasees or otherwise for any and all injuries that I may suffer, including injuries I might cause myself, any injury that may be caused to me by any other skater(s), and any injury I may suffer in any other manner. I have read this assumption of risk agreement and acknowledgement and I accept responsibility; I fully understand its terms, and I understand that I have given up substantial rights by signing it, and I sign it freely and voluntarily without any inducement.
Participants Name_________________________________________
Social Security Number ______________--_____--______________
Signature _________________________________Date___________ *Provide a copy of your driver’s license when submitting this form.